Provider Demographics
NPI:1649387317
Name:DAHLGREN, MARY ANN (DC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:DAHLGREN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:POB 878 620 W US 10
Mailing Address - Street 2:
Mailing Address - City:EVART
Mailing Address - State:MI
Mailing Address - Zip Code:49631-0878
Mailing Address - Country:US
Mailing Address - Phone:231-734-5891
Mailing Address - Fax:
Practice Address - Street 1:POB 878 620 W US 10
Practice Address - Street 2:
Practice Address - City:EVART
Practice Address - State:MI
Practice Address - Zip Code:49631-0878
Practice Address - Country:US
Practice Address - Phone:231-734-5891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301005956111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP11230121OtherMULTIPLAN
MI4750528Medicaid
MIP25907FOtherBC NETWORK
MI0F75198Medicare ID - Type Unspecified
MIP25907FOtherBC NETWORK